The One Who Held Her Hand

IntroductionBefore tracheal intubation, it is essential to provide sufficient oxygen reserve for emergency patients with full stomachs. Recent studies have demonstrated that high-flow nasal oxygen (HFNO) effectively pre-oxygenates and prolongs apneic oxygenation during tracheal intubation. Despite its effectiveness, the use of HFNO remains controversial due to concerns regarding carbon dioxide clearance. The air leakage and unknown upper airway obstruction during HFNO therapy cause reduced oxygen flow above the vocal cords, possibly weaken the carbon dioxide clearance.MethodsPatients requiring emergency surgery who had fasted < 8 h and not drunk < 2 h were randomly assigned to the high-flow group, who received 100% oxygen at 30–60 L/min through nasopharyngeal airway (NPA), or the mask group, who received 100% oxygen at 8 L/min. PaO2 and PaCO2 were measured immediately before pre-oxygenation (T0), anesthesia induction (T1), tracheal intubation (T2), and mechanical ventilation (T3). The gastric antrum’s cross-sectional area (CSA) was measured using ultrasound technology at T0, T1, and T3. Details of complications, including hypoxemia, reflux, nasopharyngeal bleeding, postoperative pulmonary infection, postoperative nausea and vomiting (PONV), and postoperative nasopharyngeal pain, were recorded. The primary outcomes were PaCO2 measured at T1, T2, and T3. The secondary outcomes included PaO2 at T1, T2, and T3, CSA at T1 and T3, and complications happened during this trial.ResultsPre-oxygenation was administered by high-flow oxygen through NPA (n = 58) or facemask (n = 57) to 115 patients. The mean (SD) PaCO2 was 32.3 (6.7) mmHg in the high-flow group and 34.6 (5.2) mmHg in the mask group (P = 0.045) at T1, 45.0 (5.5) mmHg and 49.4 (4.6) mmHg (P < 0.001) at T2, and 47.9 (5.1) mmHg and 52.9 (4.6) mmHg (P < 0.001) at T3, respectively. The median ([IQR] [range]) PaO2 in the high-flow and mask groups was 404.5 (329.1–458.1 [159.8–552.9]) mmHg and 358.9 (274.0–413.3 [129.0–539.1]) mmHg (P = 0.007) at T1, 343.0 (251.6–428.7 [73.9–522.1]) mmHg and 258.3 (162.5–347.5 [56.0–481.0]) mmHg (P < 0.001) at T2, and 333.5 (229.9–411.4 [60.5–492.4]) mmHg and 149.8 (87.0–246.6 [51.2–447.5]) mmHg (P < 0.001) at T3, respectively. The CSA in the high-flow and mask groups was 371.9 (287.4–557.9 [129.0–991.2]) mm2 and 386.8 (292.0–537.3 [88.3–1651.7]) mm2 at T1 (P = 0.920) and 452.6 (343.7–618.4 [161.6–988.1]) mm2 and 385.6 (306.3–562.0 [105.5–922.9]) mm2 at T3 (P = 0.173), respectively. The number (proportion) of complications in the high-flow and mask groups is shown below: hypoxemia: 1 (1.7%) vs. 9 (15.8%, P = 0.019); reflux: 0 (0%) vs. 0 (0%); nasopharyngeal bleeding: 1 (1.7%) vs. 0 (0%, P = 1.000); pulmonary infection: 4 (6.9%) vs. 3 (5.3%, P = 1.000); PONV: 4 (6.9%) vs. 4 (7.0%, P = 1.000), and nasopharyngeal pain: 0 (0%) vs. 0 (0%).ConclusionsCompared to facemasks, pre-oxygenation with high-flow oxygen through NPA offers improved carbon dioxide clearance and enhanced oxygenation prior to tracheal intubation in patients undergoing emergency surgery, while the risk of gastric inflation had not been ruled out.Trial registrationThis trial was registered prospectively at the Chinese Clinical Research Registry on 26/4/2022 (Registration number: ChiCTR2200059192).

Transient postviral vocal cord dysfunction

Bilateral Cricoarytenoid Joint Ankylosis with a Perplexing Etiology

Laryngopharyngeal Reflux: Beauty is in The Eye of The Beholder

Personal protective equipment has become an important and emotive subject during the current coronavirus disease 2019 epidemic. Coronavirus disease 2019 is predominantly caused by contact or droplet transmission attributed to relatively large respiratory particles which are subject to gravitational forces and travel only approximately 1 metre from the patient. Airborne transmission may occur if patient respiratory activity or medical procedures generate respiratory aerosols. These aerosols contain particles that may travel much longer distances and remain airborne longer, but their infective potential is uncertain. Contact, droplet and airborne transmission are each relevant during airway manoeuvres in infected patients, particularly during tracheal intubation. Personal protective equipment is an important component, but only one part, of a system protecting staff and other patients from coronavirus disease 2019 cross-infection. Appropriate use significantly reduces risk of viral transmission. Personal protective equipment should logically be matched to the potential mode of viral transmission occurring during patient care - contact, droplet or airborne. Recommendations from international organisations are broadly consistent, but equipment use is not. Only airborne precautions include a fitted high-filtration mask, and this should be reserved for aerosol generating procedures. Uncertainty remains around certain details of personal protective equipment including use of hoods, mask type and the potential for re-use of equipment.

Chronic cough is a common symptom,at least 10% of cases is refractory to medical treatment of common diseases,some conditions may be related to vocal cord dysfunction.Vocal cord dysfunction is a respiratory disorder caused by paradoxical closure of the vocal cords during the respiratory cycle,present as obstructive airway symptoms,or only chronic cough in some cases.Speech pathology management is effective for chronic cough caused by vocal cord dysfunction. Key words: Chronic cough; Vocal cord dysfunction; Speech pathology

You have accessThe ASHA LeaderFeature1 Jul 2006Sniffs, Gasps, and CoughsIrritable Larynx Syndrome Across the Lifespan Mary Sandage Mary Sandage Google Scholar More articles by this author https://doi.org/10.1044/leader.FTR5.11092006.16 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Irritable Larynx Syndrome (ILS) (Morrison, Rammage & Emami, 1999) has as its central thesis the idea that we can develop neuroplastic changes in the brain when a threshold of tolerance to an irritation in the upper airway or larynx is passed, creating conditions which may include chronic cough and paradoxical vocal fold motion (PVFM). This model is appealing for patients who have been told by health care providers, likely out of frustration, that they should “just quit coughing” or “just breathe.” It is helpful to consider that perhaps it isn’t in the patient’s head. Widdicombe and Singh (2006) recently published a review of the literature that addresses how cough can be “down-regulated,” including voluntary suppression of cough as a likely but little-studied mechanism. Little has been published about the speech-language pathologist’s role in the assessment and treatment of PVFM and even less has been written about behavioral intervention for chronic cough. While these areas of assessment and treatment do not directly impact communication like dysphagia, no behavioralist knows the anatomy and physiology of the vocal folds and upper airway better than SLPs. While chronic cough and PVFM share many features, I will discuss them separately to honor the nuances of each. Chronic Cough Florence Blager (1988) was the first to describe a behavioral intervention for chronic or habitual cough. Cough becomes chronic if it lasts for more than three weeks, is not related to an active infection or disease process (Irwin, et al., 1998), and presents as a dry cough without productive mucous. Fatigue, change in social function (e.g., avoiding restaurants), and trouble sleeping are common physiologic complications, with few reporting associated hoarseness. Patients may range in age from school-aged children to older adults, with the average length of coughing lasting from months to years. Most have tried many medical interventions without resolution of the cough. Medical Management In the absence of pulmonary disease or infection, postnasal drip, asthma, and/or gastroesophageal reflux disease (GERD) are considered the primary causes for chronic cough most of the time in a non-smoker (Irwin, et. al., 1998; Morice, et al., 2004). Children can develop chronic cough for many of the same reasons as adults; however, pediatric cough is less well understood. Medical management should include assessment and treatment for pulmonary disease, asthma, postnasal drip syndrome/rhinitis, gastroesophageal or laryngopharyngeal reflux disease (LPR), and extrathoracic obstruction prior to referral to an SLP. Endoscopic assessment of the larynx should be completed on all patients to rule out laryngeal pathology that may trigger cough without degrading voice quality, e.g., contact ulcer, and assess for clinical signs of reflux. Once the larynx has been visualized and the SLP is certain that all medical management has been fully explored, it is appropriate to move ahead with behavioral intervention to reduce or eliminate chronic cough. The Role of the SLP A thorough review of the patient’s medical history is vital. Unfortunately, in my clinical experience, medical conditions triggering cough have sometimes been overlooked or under-treated, such as dysphagia or LPR, requiring referral back to the physician for further medical management. Discerning the pattern and frequency of cough as well as identifying trigger(s) for cough provide the necessary information to establish a behavioral plan. Ask detailed questions about the nature and pattern of the cough. Intervention can be best described in three steps: improve the environment of the larynx to reduce irritation; train awareness of the sensations and behaviors that precipitate the cough; and implement a behavior that will delay/eliminate the cough before it happens to recalibrate the sensitivity threshold. In addition to medical management to reduce laryngeal irritation that may trigger cough, it is important to counsel patients to eliminate other agents that may be exacerbating coughing such as menthol cough drops, gargling, dry environment, mouth breathing, and dietary components that exacerbate GERD or LPR. Encourage patients to hydrate and eat “wet” snacks (e.g., apple, melon, pear, cucumber), swallow frequently, increase the humidity in the work or home environment, and breathe in through the nose. Secondly, focused attention to the physiological precursors to cough is critical for success (e.g., dry tickle). Ask the patient to learn more about any environmental or behavioral influences (e.g., desk is under heating vent). Finally, several short periods per day of active cough suppression will build focused attention and enhance success for delaying or inhibiting cough. Patients are asked to choose from the following behaviors and use one or more instead of coughing: taking ice chips or cold water, hard swallow, hard swallow with laryngeal repositioning, or nasal inhalation, which keeps vocal folds open, humidifies air, and redirects attention away from cough. Children, school-aged and older, also can benefit from this approach; however, they will likely require a longer generalization period. Follow-up at one-week and one-month intervals is important to refine the behavioral plan, facilitate carryover, and promote reduction/resolution of the cough. Paradoxical Vocal Fold Motion PVFM occurs when the vocal folds approximate or approach each other, particularly during inspiration, creating a narrow airway. Some patients produce stridor, the sound made when the vocal folds draw together during inspiration. PVFM is also called vocal cord dysfunction (VCD) and these terms are used interchangeably. PVFM continues to be frequently misdiagnosed as asthma or, if it co-occurs with asthma, it may not be recognized as a separate disorder. This disorder is more common in females and has been documented in patients from infancy to geriatrics (Heatley & Swift, 1996; Maschka, et al.,1997), with most patients falling between 10 and 40 years of age (Kuppersmith, Rosen, & Wiatrak, 1993). PVFM in athletes is more prevalent (about 5%) than first thought (Rundell & Spiering, 2003). The three primary causes for PVFM are upper airway sensitivity to laryngeal irritants (e.g., GERD/LPR, allergens/inhaled irritants, and post-nasal drip), psychological conditions, and laryngeal dystonia/dyskinesia (Mathers-Schmidt, 2001). Because the primary role of the upper airway or vocal folds is airway protection to ensure survival, the larynx is equipped with mucosal chemoreceptors, which, when irritated, signal the vocal folds to narrow or close. Irritating gas, such as from a chemical lab or factory; smoke; fumes (e.g., printed materials; vapor, e.g., sulfur dioxide, cleaning agents; mist; and dust) are documented triggers in patients with PVFM (Perkner et al., 1998). LPR may be a common, unrecognized trigger in children (Powell, et al., 2000). Initially, PVFM was believed to be triggered primarily by psychological conditions. Caution must be taken to avoid indicating that the breathing disorder is “all in the head.” This disorder has been described in infants and in children too young to demonstrate a conversion disorder or other psychiatric condition, which suggests that physiological triggers may play a primary role (Bless & Swift, 1993). The neurological form of PVFM, diagnosed as episodic laryngeal dyskinesia or adductor laryngeal breathing dystonia, is rare and likely will not respond to behavioral methods, requiring medical intervention such as surgery, medication, botulinum toxin, or tracheostomy (Worley, Witsell, & Hulka, 2003; Maschka, et al., 1997). This form of PVFM will typically present as persistent inspiratory stridor during waking hours, with no reports of discrete breathing “attacks,” and is often accompanied by dystonia or tremor in other parts of the body. Medical Assessment Like chronic cough, PVFM requires thorough medical assessment prior to referral to an SLP. The differential diagnoses that are considered during the initial medical work-up for reports of inspiratory stridor include asthma attack; gastroesophageal reflux; laryngeal pathology (e.g., laryngeal edema secondary to allergen, unresolved laryngomalacia, bilateral vocal fold paralysis, laryngeal mass); PVFM/VCD; and panic attack. An endoscopic assessment of the upper airway, completed by the SLP or an otolaryngologist, is necessary to rule out an obstruction, which would cause both inspiratory and expiratory stridor, particularly with exertion or laying flat on the back, during waking, resting, and sleeping. A thorough pulmonary assessment should be completed to definitively determine if the patient has asthma. A formal allergy assessment also will be warranted for patients who describe allergens as triggers for the breathing events. Patients with PVFM likely will report that they have only partially responded or not responded at all to empirical treatment for asthma and/or allergies. To make matters more confusing, about half of patients with PVFM also have asthma. There are distinct differences between asthma and PVFM/VCD (see Table on page 17). The Role of the SLP Extensive knowledge of likely triggers, medical management of those triggers, and behavioral methods for intervention are necessary to adequately serve this population. SLPs should allow patients to tell about their breathing difficulties, letting the stories unfold with some guidance and taking care not to lead the patient in a specific direction. Although these patients share common features, their unique presentations will inform a personalized behavioral treatment plan for recovery. The severity of the breathing challenge can be assessed using information about the frequency and intensity of the attacks. Frequency may range from two attacks per month to 20 per day and a single “attack” may last from a few seconds to several minutes. PVFM Treatment Most patients will require medical management of the trigger(s) in order to support the breathing recovery exercises. The environment of the larynx must be improved to allow the breathing recovery exercises to be effective, eventually recalibrating the sensitivity of the larynx back to a typical threshold. Medical intervention may include reflux management, nasal drainage management, and asthma or allergy symptom control as warranted. There are three basic steps for behavioral treatment: training awareness, training relaxed belly breathing, and finally, training the actual breathing recovery method. The behavioral program is described in detail in the literature (Mathers-Schmidt, 2001; Sandage & Zelazny, 2004). While the first step may appear unnecessary, I learned the hard way that patients are more successful with the program if their awareness to subtle changes in the body has been conditioned. This is accomplished through an exercise that is much like progressive relaxation; however, the objective is not necessarily to relax, but to develop the ability to attend to or notice very small changes in the body. This heightened attention trains patients to notice any physiologic sign that a breathing attack is imminent so that they can start the breathing exercise before the paradoxical behavior begins. Secondly, the perception of air hunger promotes changes in breathing patterns that can exacerbate the feeling of breathlessness. Many patients with PVFM have extraneous neck and shoulder tension and rely on high-chest breathing. The goal is to re-establish belly expansion when inhaling, with belly collapse when exhaling while maintaining relaxed shoulders, neck, and jaw. During the final step, the patient learns specific breathing patterns to use when feeling the onset of a PVFM attack to keep the vocal folds open during inhaling and exhaling. If the recovery exercise is started before the paradoxical behavior starts, the patient should be able to avoid an event completely, even if the onset occurs during extreme physical exertion as with athletes. The therapeutic process generally takes between three to five visits following the initial assessment. SLPs are successfully applying behavioral methods to reduce or eliminate chronic coughing and PVFM. Once the patient experiences a few weeks without any cough or breathing difficulties, the patient may be referred back to the physician to determine if unnecessary medications can be discontinued, e.g., rescue inhalers, reflux medication. If behavioral intervention fails, the patient should be referred back to the physician for consideration of other medical interventions as previously described. Symptom Differences Between PVFM/VCD and Asthma PVFM/VCD, Asthma Breathing difficulty occurs during…, Inhalation (stridor), Exhalation (wheeze) Sound originates in …, Neck, Chest Area of constriction is…, Throat tightness, Chest tightness Symptoms peak…, Shortly after starting exercise and resolves within several minutes of exercise cessation, Between 5 & 20 minutes after exercise stops Responds to rescue inhalers, No, Yes Focus on Divisions Division 16, School-Based Issues focuses on professional issues for speech-language pathologists working in the school environment. The Division offers affiliates the opportunity to earn CEUs through self-study of the Division publication, Perspectives (published four times annually), an exclusive e-mail list and Web forum, and other benefits. Visit Division 16’s Web page to learn more about Division 16. Division 1, Language Learning and Education focuses on research and professional issues related to normal and disordered language learning and education, including intervention and treatment of the school-aged population. The Division offers affiliates the opportunity to earn CEUs through self-study of the Division publication, Perspectives (published three times annually), an exclusive e-mail list and Web forum, and other benefits. Visit Division 1’s Web page to learn more about Division 1. References Blager F. B., Gay M. L., & Wood R. P. (1988). Voice therapy techniques adapted to treatment of habit cough: a pilot study.Journal of Communication Disorders, 21, 393–400. CrossrefGoogle Scholar Bless D. M., & Swift E. (1993, October). Paradoxical vocal fold movement. Presented at the Pacific Voice Conference, San Francisco. Google Scholar Heatley D. G., & Swift E. (1996). Paradoxical vocal cord dysfunction in an infant with stridor and gastroesophageal reflux.International Journal of Pediatric Otorhinolaryngology, 34, 149–151. CrossrefGoogle Scholar Irwin R. S., Boulet L., Cloutier M. M., Fuller R., Gold P. M., Hoffstein V., et al. (1998). Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American college of chest physicians.Chest, 114(2), 133S–181S. CrossrefGoogle Scholar Kuppersmith R., Rosen D. S., & Wiatrak B. J. (1993). Functional stridor in adolescents.Journal of Adolescent Health, 14, 166–171. CrossrefGoogle Scholar Maschka D. A., Bauman N. M., McCray P. B., Hoffman H. T., Karnell M. P., & Smith R. J. H. (1997). A classification scheme for paradoxical vocal cord motion.The Laryngoscope, 107, 1429–1435. CrossrefGoogle Scholar Mathers-Schmidt B. A. (2001). Paradoxical vocal fold motion: A tutorial on a complex disorder and the speech-language pathologist’s role.American Journal of Speech-Language Pathology, 10, 111–125. ASHAWireGoogle Scholar Morice A. H., Fontana G. A., Sovijarvi A. R. A., Pistolesi M., Chung K. F., Widdicombe J., et al. (2004). The diagnosis and management of chronic cough.European Respiratory Journal, 24, 481–492. CrossrefGoogle Scholar Morrison M., Rammage L., & Emami A. J. (1999). The irritable larynx syndrome.Journal of Voice, 13(3), 447–455. CrossrefMedlineGoogle Scholar Perkner J. J., Fennelly K. P., Balkissoon R., Bartelson B. B., Ruttenber A. J., Wood R. P., & Newman L. S. (1998). Irritant-associated vocal cord dysfunction.Journal of Occupational & Environmental Medicine, 40(2), 136–143. CrossrefGoogle Scholar Powell D. M., Karanfilov B. I., Beechler K. B., Treole K., Trudeau M. D., & Forrest L. A. (2000). Paradoxical vocal fold dysfunction in juveniles.Archives of Otolaryngology and Head Neck/Surgery, 26, 29–34. CrossrefGoogle Scholar Rundell K. W. & Spiering B. A. (2003). Inspiratory stridor in elite athletes.Chest, 123(2), 468–474. CrossrefGoogle Scholar Sandage M. J. & Zelazny S. K. (2004). Paradoxical vocal fold motion in children and adolescents.Language, Speech, and Hearing Services in Schools, 35, 353–362. ASHAWireGoogle Scholar Widdicombe J. & Singh V. (2006). Physiological and pathophysiological down-regulation of cough.Respiratory Physiology & Neurobiology, 150, 105–117. CrossrefGoogle Scholar Worley G. W., Witsell D. L., & Hulka G. F. (2003). Laryngeal dystonia causing inspiratory stridor in children with cerebral palsy.The Laryngoscope, 113, 2192–2195. CrossrefGoogle Scholar Author Notes Mary Sandage, is an SLP in Auburn, AL where she is in private practice and is a part-time course and clinic instructor in the Communication Disorders Department at Auburn University. Contact her by e-mail at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 11Issue 9July 2006 Get Permissions Add to your Mendeley library History Published in print: Jul 1, 2006 Metrics Current downloads: 6,498 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2006 American Speech-Language-Hearing AssociationLoading ...

ROLE OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN SALVAGE THERAPY FOR CENTRAL AIRWAY OBSTRUCTION: A CASE REPORT

Concluding his theme of Protestant nostalgia, Fraser here focuses on a particular moment in historical time: the Restoration of the English monarchy in 1660 when, fresh from his continental exile, Charles II returned to London resolved to revive English entertainment, music and theatre. Fraser then recounts how the honeymoon period immediately subsequent to this event was followed by a phase of retrenchment, when a growing suspicion of Catholic tendencies at court obliged authors and composers to cut their cloth more narrowly. The chapter then takes a close look at a particular crisis which brought these tensions to a head: the “Popish Plot” of 1678, when the circles surrounding the Portuguese Catholic queen were subjected to a cloud of suspicion. The reaction of artists and musicians was various, but Fraser again focuses on one salient figure, the young composer Henry Purcell, organist of Westminster Abbey. In that year Purcell composed an anthem in Latin, a setting of a psalm seemingly expressive of the king’s sense of apprehension and isolation. As Fraser argues, the fact that the text set was in Latin is itself very significant. Even more so was that the translation that Purcell chose was by one of the most exotically cosmopolitan scholars of the age: an Italian and Jewish exile from Ferrara who had converted to Protestantism, sought sanctuary in England and then fled to the Low Countries, where his translation of the Old Testament from Hebrew finally saw the light of day.

A 52-Year-Old Man Who Smokes With Rapidly Progressive Respiratory Failure

Temporary Vocal Fold Augmentation Outcomes for Refractory Chronic Cough with Concurrent Nonparalytic Glottic Insufficiency due to Vocal Fold Atrophy

Background: Head and neck soft tissue sarcomas are rare and leiomyosarcoma accounts for only 4% [1] . There have only been 50 cases of glottic leiomyosarcomas reported in scientific literature to date. Immunohistochemistry is pivotal in establishing diagnosis. Surgery remains mainstay of treatment for glottic leiomyosarcomas. We report a case of glottic leiomyosarcoma. Case Description: A 53-year-old gentleman with no comorbidities, presented in January 2017 with progressive hoarseness of voice over six months. There was no dysphagia, odynophagia, dyspnoea, cough, or constitutional symptoms. Clinical examination of the neck was unremarkable. Flexible scope showed a pedunculated mass at subglottic, anterior commissure, and left vocal cord. Subsequent direct laryngoscopy revealed a mass arising from anterior two-thirds of left vocal cord extending to anterior commissure and subglottic area. Excisional biopsy on 13/1/2017 reported histopathological finding of leiomyosarcoma. Immunohistochemistry showed positivity for SMA, vimentin and EMA. Computed tomography on 28/2/2017 revealed a glottic soft tissue lesion measuring 0.8 × 0.8 cm with neither involvement of the surrounding structures nor distant metastasis. Patient subsequently underwent total laryngectomy. Intraoperatively, a mass was seen at the anterior commissure (left > right) extending 5 mm below vocal cord with levels II, III right cervical lymphadenopathy. The histopathological report revealed a firm, whitish 1.3 × 1.0 × 1.0 cm leiomyosarcoma, FNCLCC Grade 2. Resected lymph nodes were negative and resection margins were clear (closest margin 3cm). Conclusion: Due to rarity of cases, survival statistics and treatment options in vocal cord leiomyosarcoma are not well established. Treatment principles are extrapolated from sarcomas of other sites, with extirpative surgery with wide margins is preferred, whenever feasible. Adjuvant radiotherapy may be recommended for high grade tumours, especially those with close/involved margins for better local control. The role of adjuvant chemotherapy remains uncertain but may be considered in fit patients with high risk of recurrence. More case studies are required to consolidate the management of this rare malignancy.

The methods of surgical treatment of bilateral posticus paralysis are classified into 2 groups;1) tracheotomy with permanent metal cannula, 2) intralaryngeal or extralayngeal laterofixation of the vocal cord with or without aryectomy.The laterofixation of the vocal cord is very useful operative procedure to alleviate the dyspnea and to sustain the serviceable voice;however, in order to restore the laryngeal airway, some impairment of the phonatory function is always seen.After the tracheotomy patients' respiration is free and their voice is clear, however, a tracheotomy tube is considerably troublesome because of the annoying cough, granulation at the tracheal stoma, bleeding and pain caused by the cannula.The tracheal fenestration is a permanent airtight, leakproof, skinlined tracheocutaneous communication that was deviced by Rockey 1956.The external opening of this skin tube is guarded by two door-like valves which normally are in apposition and prevent the leakage of air or liquid.These valves may be mannually opened, occasionally by retroflexion of the head or by insertion of the small tube into the stoma at will.The tracheal fenestration does not have such disadvantages as conventional tracheotomy with metal canuula has, and the patients' voice is not impaired.The author reported two cases of bilateral posticus sralysis treated by the tracheal fenestration opera*ion.The first case can respirate through the tracheal opening as well as the glottis.He can normally phonate and cough in the prone position of the head.The second case uses a small tube at night;however, she does without cannula by day and her voice is not impaired.

Objective To investigate the effect of different doses of dexmedetomidine for conscious blind nasotracheal intubation. Methods Fifty-one ASA?～? patients undergoing general anesthesia for elective surgery were randomly divided into 3 groups.The type of anesthesia for tracheal intubation (n = 17 each ): group ? received surface anesthesia only; group ? and ? received dexmedetomidine 0.5 or 1.0 礸/kg on top of surface anesthesia. All patients received surface anesthesia of nasal cavity, pharynx and larynx, trachea with 1% tetracaine. In group ? and group ? Dexmedetomidine 燞 ydrohloride 營 njection (batch number 10061434, approved number H20090248, produced by Jiangsu HengRui pharmaceutical Co., LTD) was diluted reach to 4 μ g/ml with the 0.9% sodium chloride solution. Then Dexmedetomidine 0.5 or 1.0 礸/kg Ⅳ 15 min. 1 min later conscious blind nasotracheal intubation was operated. MAP, HR and SpO2 were continuously monitored and recorded before anesthesia (T0), before trachea cannula (T1), when tracheal tube was inserted into nasal (T2) and advanced through vocal cords into trachea (T3). Responses like nausea,coughing and restlessness were also recorded. The patient 抯 awareness of the intubation was noted after operation. Results MAP and HR were significantly increased at T2 and T3, compared with them at T0 in group ?(P＜ 0.05). MAP was significantly decreased at T1, compared with it at T0 (P＜ 0.05); while MAP and HR were significantly increased at T3, compared with then at T0 in group Ⅱ (P＜ 0.05).MAP was significantly decreased at T1 、 T2and T3, compared with it at T0 (P＜ 0.05);and HR was significantly decreased at T1,compared with it at T0 (P＜ 0.05) in group ?. MAP and HR were significantly increased at T1、 T2 and T3 in group ?, compared with them in group ? and ? (P＜ 0.01). SpO2 was significantly decreased at T3in group ?,compared with it in group ? and ? (P＜ 0.01). MAP was significantly decreased at T1 、T2and T3 in group ?,compared with it in group ? (P＜ 0.05). HR was significantly decreased at T2and T3 in group ? ,compared with it in group ? (P＜ 0.05). The incidence of coughing, restlessness and awareness of the intubation were significantly lower in group ? than in group ? (P＜ 0.05). The incidence of nausea coughing, restlessness and awareness of the intubation were significantly lower in group ? than in group ? (P＜ 0.01). The incidence of nausea, coughing, restlessness and awareness of the intubation were significantly lower in group ? than in group ? (P＜ 0.05). Conclusion Dexmedetomidine 1.0 礸/kg given via Ⅳ slowly on top of surface anesthesia with 1% tetracaine can provide a good intubation condition with less intubation response for conscious blind nasotracheal intubation. It抯 safe and effective. Key words: Dexmedetomidine; Conscious blind nasotracheal intubation; Conscious sedation

A polio-free world?